How land, jobs and water decide which children starve
Nnasaretha Kgamanyane | Tuesday April 28, 2026 09:05
This is the story of why acute malnutrition keeps finding the San community first and what it will take to break the cycle.
In most of the affected families, the building structures are made of mud and tree branches, thatched with grass. The rooms have no beds and more than ten people sleep in them. Most of those yards have two or less rooms. Outside on of them, a nine-month-old baby who had just graduated from a malnutrition treatment programme sat on his mother’s lap.
He is a member of a family of 22 in Refilwe Tsotsi’s homestead in Khwee. The 24-year-old has four children and two of them are underweight. The nine-month-old boy was diagnosed with acute malnutrition. Five of the children in the yard are under five.
Last week, UNICEF, the Embassy of Japan, and the Botswana Red Cross hosted a monitoring visit to Boteti as part of the Community Management of Acute Malnutrition programme, or CMAM. The programme began in November 2025 after a high-level national engagement in mid-2024. It targets five high-burden districts selected by the Ministry of Health. These include Ghanzi, Hukuntsi, Mabutsane, Letlhakeng and Boteti. The goal is to ensure that no child experiences preventable malnutrition.
But a pattern is emerging. In Ghanzi, in Mabutsane and now in Boteti, the children found with acute malnutrition have almost always been San. In every region visited so far, the San community, also called Basarwa, is the one facing the worst of it. The question is why malnutrition keeps finding the same people.
“In all the regions that had been found with acute malnutrition, the San community is always the one mostly affected,” said a member of the monitoring team. “This is a cause for concern.”
Tsotsi explained that her child was declared to be malnourished when he got sick and had diarrhoea.
“We visited a local clinic and we were admitted and we were told that my son had diarrhoea because of cattle milk,” she said. “Whenever there is no food at home, we migrate to the cattle post in search of food. “My son was then enrolled in the feeding scheme and treatment.”
Her other child was also found with malnutrition but Tsotsi explained that they left the child at the cattle post with his uncle so that he could have something to eat and gain weight.
Feeding them is a daily negotiation. Tsotsi and her boyfriend are both unemployed. Most of the 22 family members in the yard do not have jobs. To eat, they migrate.
“We go quite often to the cattle post where my boyfriend’s brother works so that we can find something to eat. “At the cattle post we can drink milk from the cows and eat maize meal and sometimes meat. At the village, food runs out quickly.”
A few yards away, Kebatshabile Motlhaping’s family is raising 12 people in one household, ten children and two adults. Her grandson was also recently diagnosed with acute malnutrition. His mother is a tertiary student in Gaborone and left the baby with a younger sibling who could not manage whilst at school. Since entering CMAM, the boy has gained weight.
“The boy has gained weight and was doing very well,” his grandmother said. “However, it is still hard for the family to put enough food on the table.”
In Letlhakane, the problem deepens, particularly in Buuhe, one of the areas worst affected by malnutrition among children under five. This is also where many Basarwa reside.
Oelatotse Hebetsho lives with her husband and 15 children and grandchildren in Extension One. Her daughter, Gohitlhetsemang Gabankitse’s, son was diagnosed with acute malnutrition. Gabankitse is the sole breadwinner and works as a maid. Her P700 salary can only buy a food combo.
“I am a single parent and it is hard to buy enough food for my family,” she said.
Hebetsho’s other son works as a herdsman and helps where he can, but the money is not enough.
“We were staying at the ranch before the owner sold his farm,” Hebetsho explained. “We had to move back to Letlhakeng with our father who is also not well,”. “We do not receive any help from social workers because our yard is ungazetted.”
The family moved from her father’s house because they were too many. Her other siblings and their children stay with their father who is disabled and gets help from social workers.
“Whenever his food comes, we go and get our small share because as Basarwa we believe in sharing,” she said.
The yard has no proper shelter, no water and no toilets. Living in such unhygienic area contributes to the family’s vulnerability to diseases.
This is the thread that ties Khwee to Buuhe to Ghanzi. A thread of landlessness, joblessness and ungazetted plots that make families invisible to services. When farms are sold, San workers are replaced. They return to villages with no land allocation, no income and no infrastructure. Households swell to 15, 20, 22 people and children share not just rooms, but rations. Illness spreads fast and when diarrhoea hits, weight gain stops.
Boteti has 9,951 children under five, according to Statistics Botswana figures. The district target for underweight prevalence is 2.9 percent. In July 2025, before CMAM started in December, Khwee recorded an underweight prevalence of 18.2 percent or about 64 children. In August, this climbed to 20 percent or roughly 70 to 71 children.
“These numbers really put children at risk of not reaching their full potential in school, in families and in life,” said Dr. Kimanzi Muthengi of UNICEF Botswana during the district briefing. “The first 1,000 days determines a child’s ability to grow, learn and contribute to the country’s development. “No child in Boteti should be left behind because of malnutrition.”
District data from quarter two of 2025 showed child welfare clinic attendance at 90 percent, above the 80 percent target. But underweight prevalence and stunting were above target. Ration coverage was 64 percent against a target of 85 percent. Khwee and Letlhakeng Clinic were classified as “high concern,” with underweight prevalence above 10 percent. Since CMAM began, both have improved and are no longer in the high concern category.
But progress is fragile. Food commodities have been in short supply since January 2026. Transport to remote areas is limited and high defaulter rates follow when rations stop.
“Most of the caregivers don’t bring their children to child welfare clinics,” district health officials said.
Alcohol abuse, poor feeding practices, childhood illnesses, and the sharing of Tsabana rations also undercut gains.
Boteti District Council Secretary, Mpaphi Kgomotso, said CMAM was designed to reach underserved and hard to access populations through volunteers and community co-design. However the San are not just hard to access. They are structurally excluded and unemployment is near total in the households visited. Cattle posts are lifelines, while social worker support misses ungazetted yards. Without land, water, or jobs, nutrition becomes a cycle of migration and sharing that no feeding scheme can fix alone.
“If you can find someone who can come in Boteti and invest with us, we will be happy,” Council chairperson, Onkhuparetse Monnaatsie told the delegation. “Because we know that if we can find an investor and then we start to do business, those people, we can hire them in large numbers. “There are no jobs in Boteti and we rely on mines but now there’s a problem because the mines are closed.”
CMAM provides direct feeding in Khwee and Buuhe, food rations of Tsabana, Malutu, beans and cooking oil, as well as Ready-to-Use Therapeutic Food for wasted children. The programme trains frontline workers and volunteers, supports mothers and intensifies growth monitoring across 21 clinics and 258 mobile outreach points.
“This high-level monitoring visit goes beyond reviewing progress,” Kgomotso said. “It is an opportunity to strengthen partnerships and also an opportunity to hear community voices. “It is an opportunity to reaffirm our shared commitment to ensuring that no child experiences preventable malnutrition.”
UNICEF’s commitment is to provide technical support, supplies and monitoring, while the Embassy of Japan funds the programme through its supplementary budget.
“The Government of Japan is supporting this project, but not directly. We are not on the ground,” said the Ambassador of Japan to Botswana, Shindo Yusuke. “I am looking forward to seeing the people in the community and also to viewing the health facilities in order to see what was achieved by the project and what can be done in the future.”
Malnutrition is not a medical event. In Khwee and Buuhe, it is a housing issue, a land issue and a jobs issue. A child graduates from CMAM heavier, then returns to a yard of 22 where the next meal depends on a brother at a cattle post. A grandmother keeps a baby alive while her daughter studies in Gaborone, but there is still not enough food. A mother splits a P700 salary between 15 people.
The statistics reflect serious health risks for children, including greater susceptibility to illness, developmental delays and long-term consequences on their overall health and well-being. But the statistics start in a room with ten people, an ungazetted plot with no toilet, and a family that believes in sharing because there is never enough not to.
The CMAM programme is treating children. It is not treating the conditions that keep producing them. Until employment, land tenure, water, sanitation, and social protection reach San families, the same children will keep appearing on clinic registers. The visit to Boteti proved that CMAM works, but it also also proved that it cannot work alone.
As the general secretary and CEO of Botswana Red Cross Society Dr Kutlwano Mukokomani said: “Together we shall reach every one of those children that have been indicated as missing in our targets in Boteti. They should not only survive, but also thrive.”
For Tsotsi’s nine-month-old, for Hebetsho’s grandson, and for the 64 children in Khwee who were underweight last July, thriving will take more than Tsabana. It will take a country deciding that no community should have to migrate for milk or food.